Intended for healthcare professionals

Clinical Review

Managing ophthalmic herpes zoster in primary care

BMJ 2005; 331 doi: (Published 14 July 2005) Cite this as: BMJ 2005;331:147
  1. Wim Opstelten, general practitioner (,
  2. Michel J W Zaal, consultant ophthalmologist2
  1. 1 Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, PO Box 85060, 3500 AB Utrecht, Netherlands
  2. 2 Department of Ophthalmology, VU University Medical Center Amsterdam, Netherlands
  1. Correspondence to: W Opstelten


    During their professional career, most general practitioners will be consulted by various patients with an acute manifestation of ophthalmic herpes zoster. In addition to the diagnostic dilemma that doctors face in the initial phase of the disease, they may be uncertain about the course and treatment (when is referral indicated, who should be prescribed antiviral medication?). We present an evidence based policy.

    Herpes zoster (shingles) is a commonly encountered disorder in general practice. One fifth of the population, mainly elderly people, will present with this neurocutaneous infection during their lifetime. Most immunocompetent patients will experience spontaneous and complete recovery within a few weeks. Some, however, will develop complications such as postherpetic neuralgia and, in cases of ophthalmic herpes zoster, sight threatening eye problems. We outline the main points that general practitioners should keep in mind when faced with a case of ophthalmic herpes zoster.


    In February 2005, we searched the Cochrane Controlled Trial Register (keyword: “herpes zoster”), Embase, and Medline (MESH terms: “herpes zoster” and “therapy”) for clinical trials, randomised controlled trials, meta-analyses, practice guidelines, and reviews. We selected only articles written in English and disregarded any studies of immunocompromised patients.

    Incidence and pathophysiology of herpes zoster

    Herpes zoster is a commonly seen disorder; one fifth of the population will present with the disease during their lifetime. The reported incidence varies from 2.2 per 1000 to 3.4/1000 people per year. Herpes zoster develops mainly in elderly people: its incidence in people aged over 80 is about 10 in 1000/year.1 2 It is caused by reactivation of the varicella zoster virus (human herpes virus type 3). In temperate climates, primary infection with this virus usually occurs before the age of 10 and manifests itself clinically as chickenpox (varicella). The virus then becomes latent, nestling in the sensory ganglia. Later it may become active again, spread to …

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